Nurse Practitioner Coding Practices in Primary Care: A Retrospective Chart Review

To describe the coding and documentation practices of nurse practitioners (NPs) when using evaluation and management (E & M) codes in an academic primary care center. Data Sources A randomized retrospective review of ten charts from a nurse-managed primary care clinic affiliated with a midwestern research-intensive university. Conclusuion The findings demonstrate that the documentation in the chart for six of the ten client encounters did not support the E & M codes assigned by the clinicis NPs. Four of these six client encounters were overcoded; the remaining two encounters were undercoded. Implications for Practice Findings of this study support the need for additional education of NPs in the areas of coding and documentation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73272/1/j.1745-7599.2003.tb00364.x.pd